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Clinical Pharmacy Services in the Emergency Department

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Clinical Pharmacy Services in
the Emergency Department
Daniel P. Hays, Pharm.D., BCPS
Director, Specialty Residency in Emergency Medicine/Critical Care
Clinical Pharmacy Specialist – Emergency Medicine
University of Rochester Medical Center
Strong Memorial Hospital
History of Emergency
Pharmacy Services
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1970’s
Billing
Inventory control
Clinical pharmacy services
1980’s led way for pharmaceutical care
1 Ellenbaas, et all
1
ED is a Unique Practice
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Many safety mechanisms not available in
ED
Pharmacy USUALLY not present
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NO DOUBLE CHECK
JCAHO supports pharmacist double check
on ALL medication orders
Unique Practice cont.
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High Patient Volume
Verbal Orders
HIGH STRESS situations
Contributing Factors to
Hazards
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Patients are strangers
Multiple patients being treated at same
time
Wide range of medications utilized
Interruptions/distractions
ED Dispensing
Time Constraints
Tight Coupling Croskerry, et.al. Academic Emergency Medicine
Reasons for Chaos
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One time orders
Little patient history
No other safety mechanism in place
Changing gears
Inpatients/outpatients co-mingling
4 times as many ED visits as OR in US!
Medication Errors in the
ED
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ED has highest rate of preventable errors
110 MILLION ED patients yearly in US*
5% experience potential events
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70% of these are PREVENTABLE**
*National Center for Health Statistics.
**Harvard Medical Study
Let’s Compare
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77% of all ED medication errors between
ordering phase and administration phase
23% of errors were discovered before
patient received medication
39% in other area of hospital
USP Patient Safety CAPS Link
Challenges to
Implementation
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Financial
Staffing
Acceptance by medical staff / turf issues
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Physicians, nursing, midlevel providers, etc
Physical space within ED
Training
Strong Memorial Hospital
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ED has > 120 beds
Over 500 doses of medication dispensed
per day
Over 90,000 patient visits per year
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60,000 adults
30,000 pediatrics
Nationally ~ 3.5% of ED’s have Pharm
presence
Pharmacist Duties in the
Emergency Department
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Clinical
Academic
Research
Administrative
Distribution
Clinical Duties
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Clinical Consultation
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Attend rounds and present patient
information
Dose recommendations
Therapeutic substitution
Disease state specific pharmacotherapy
Pharmacokinetics
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Being available – and visible!!
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Clinical Duties
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Medication history
Allergy screening
Pregnancy medication consultation
Weight based dosing
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Pediatric
Obese
Geriatric
Disease specific (CF, FTT, etc)
Clinical Duties
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Patient Education
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Medication specific education
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Asthma
Warfarin
LMWH
Diabetes
Discharge counseling
Order Review
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Allergies
Medication interactions
Inappropriate
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Dose
Route
Indication
ED is only place within SMH that has handwritten orders
The Medication Process
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Prescribing
Transcribing
Dispensing
Administering
Monitoring
Discharge Medications
Prescribing
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Incomplete knowledge of medication
Incomplete knowledge of patient
Less access to
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Patient medications prior to visit
Patient history
Transcribing
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Verbal Orders
Poor penmanship
Team communication errors
Dispensing
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Dispensed by nursing
Dispensed by physicians
Thorough counseling not
available/performed
Administration of
Medications
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Multiplicity of medications
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Therapeutic duplications
Potency of medications
Multiple patients in the ED
Parenteral administration
Drug incompatibilities
Physician administration
Monitoring
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Parenteral administration
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Esp cardiac medications, insulin, etc…
Emergency procedures
Inadequate personnel
Discharge Medications
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Complex procedures
Medicated patients leaving the ED
Chart Review
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Review all patient charts for appropriate
medication use
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Underutilization
Overutilization
Polypharmacy
Distribution
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Automated dispensing machines
CPOE for admitted patients
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Pharmacy System
PYXIS
Pharmacist available for assistance
Public Awareness
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ASHP / ACCP involvement
National EM/CC society involvement
Publications
AHRQ Grant
References
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Elenbaas, R.M., Role of the pharmacist in providing clinical
pharmacy services in the emergency department. The Canadian
journal of hospital pharmacy., 1978. 31(4): p. 123-5.
Bowles, G.C., Jr., Emergency room trends place increasing
demands on pharmacy. Modern hospital., 1966. 106(1): p. 127.
Angelides, A.P. and T.A. Manzelli, Control of emergency department
medications. Hospitals., 1966. 40(12): p. 98-102.
Maudlin, R.K. and E. Owyang, Emergency department drugs.
Hospitals., 1971. 45(9): p. 88-92.
Elenbaas, R.M., J.F. Waeckerle, and W.K. McNabney, The clinical
pharmacist in emergency medicine. American journal of hospital
pharmacy., 1977. 34(8): p. 843-6.
Kaushal R, Bates D. 2001. The clinical pharmacist.s role in preventing
adverse drug events. In: Making Health Care Safer: A Critical Analysis of
Patient Safety Practices (Evidence Report/Technology Assessment, No. 43).
Rocekville, MD: AHRQ.
References
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Spigiel, R.W. and R.J. Anderson, Comprehensive pharmaceutical
services in the emergency room. American journal of hospital
pharmacy., 1979. 36(1): p. 52-6.
Culbertson, V. and R.J. Anderson, Pharmacist involvement in
emergency room services. Contemporary pharmacy practice.,
1981. 4(3): p. 167-76.
Whalen, F.J., Cost justification of decentralized pharmaceutical
services for the emergency room. American journal of hospital
pharmacy., 1981. 38(5): p. 684-7.
High, J.L., A.W. Gill, and D.J. Silvernale, Clinical pharmacy in an
emergency medicine setting. Contemporary pharmacy practice.,
1981. 4(4): p. 227-30.
Powell, M.F., D.K. Solomon, and R.A. McEachen, Twenty-four
hour emergency pharmaceutical services. American journal of
hospital pharmacy., 1985. 42(4): p. 831-5.
References
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Kasuya, A., et al., Clinical pharmacy on-call program in the
emergency department. The American journal of emergency
medicine., 1986. 4(5): p. 464-7.
Oddis, J.A., Pharmaceutical services in the OR, ER, and ICU.
Resident and staff physician., 1986. 32(7): p. 8, 11.
Schauben, J.L., Comprehensive emergency pharmacy services.
Topics in hospital pharmacy management / Aspen Systems
Corporation., 1988. 8(3): p. 20-8.
Laivenieks, N., et al., Clinical pharmacy services provided to an
emergency department. The Canadian journal of hospital
pharmacy., 1992. 45(3): p. 113-5.
Blazys, D. and W.C.T.U.S.A.e.a.c. St Mary's Hospital, Reducing
errors with PYXIS. Journal of emergency nursing: JEN : official
publication of the Emergency Department Nurses Association.,
2002. 28(2): p. 147.
References
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Thomasset, K.B., R. Faris, and B.M.C.E.N.S.A.B.H.B.M.A.U.S.A.k.t.b.o.
Department of Pharmacy, Survey of pharmacy services provision in the
emergency department. American journal of health-system pharmacy :
AJHP : official journal of the American Society of Health-System
Pharmacists., 2003. 60(15): p. 1561-4.
Fairbanks, R.J.,Hays, D.P. et al., Clinical pharmacy services in an
emergency department. American journal of health-system pharmacy :
AJHP : official journal of the American Society of Health-System
Pharmacists., 2004. 61(9): p. 934-7.
Brown, M. and F.B.D.D.A.L.U.S.A.m.t.w.n. Bryan W Whitfield Memorial
Hospital, Medication safety issues in the emergency department.
Critical care nursing clinics of North America., 2005. 17(1): p. 65-9, xi.
Fick, D.M., et al., Updating the Beers criteria for potentially
inappropriate medication use in older adults: results of a US consensus
panel of experts. Archives of internal medicine., 2003. 163(22): p.
2716-24.
References
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Leape L, Cullen D, Dempsey Clapp M, Burdick E, Demonaco H, Ives Errickson J, Bates D. 1999.
Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.
Journal of the American Medical Association 281(3):267.270.
Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD. 1999. The potential for improved
teamwork to reduce medical errors in the emergency department. The MedTeams Research
Consortium. Annals of Emergency Medicine 34(3):373.383.
IOM report on Emergency Care 2006
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